International Journal of Infectious Diseases 109 (2021) 33–35
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International Journal of Infectious Diseases
journal homepage: www.elsevier.com/locate/ijid
Letter to the Editor
Ecuador and Covid-19: A pandemic we won't be
able to run away from
Dear Editor,
Ecuador’s response to the Covid-19 pandemic started on 26
February 2020 (Se registra el primer caso de coronavirus en
Ecuador – Secretaría General de Comunicación de la Presidencia,
2021). Several policies were implemented to reduce the number of
infections, which partially worked. However, as the virus moved
through the country, the hospitals became overwhelmed (Se
registra el primer caso de coronavirus en Ecuador – Secretaría
General de Comunicación de la Presidencia, 2021; Deutsche Welle,
2020). Most of the medical staff was transferred to Covid-19 care to
cope with the high number of cases. Medical personnel struggled
around the lack of protective personnel equipment (PPE), multiple
failed treatments (including hydroxychloroquine, antibiotic and
antiviral therapies, and various ventilation regimes), and the lack
of hospital beds (Mehta et al., 2021). Ecuador and Latin America
already had severe healthcare limitations, even in the absence of a
pandemic (Thompson et al., 2020). The country was not prepared
for this disease, and it came with great cost. The world witnessed
the human toll that Covid-19 caused in places like Italy, Spain, and
New York (Adibe, 2021). It was only a matter of time before places
like Brazil, Colombia, Guayaquil, and Quito had their turn (Se
registra el primer caso de coronavirus en Ecuador – Secretaría
General de Comunicación de la Presidencia, 2021). As the
unprepared healthcare workforce tried to face this deadly and
unknown disease, the remainder of the population fought against
one another (How COVID-19, 2020; The Great Lockdown, 2021;
Ontiveros, 2020). The lack of economic resources, job opportu-
nities, and interruptions on schooling plunged the economy into
one of the worst recessions the region has ever faced and will likely
impact behavior for decades (Yo Me Cuido, 2020; Giusti et al.,
2020).
In Ecuador, even though it was known that lifting restrictions
could cause a rise in cases (as happened in places like Spain, Italy,
and Germany), the government completely lifted travel restric-
tions and curfew restrictions on 12 September 2020 and
implemented a new health policy, which was far from ideal
(Waters, 2020). Social distancing, alcohol, and hygiene measures
were implemented; nonetheless, the virus was and is still here. It
spread again very quickly, causing a new spike in cases and more
workload on the already exhausted medical personnel (Noonan,
2020; Hospitales enfrentan subida de casos con las UCI a tope,
2021). Surgeons, especially young ones, worked alongside
gynecologists, traumatologists, anesthesiologists, and other surgi-
cal specialists, and assumed the roles of clinicians and continued to
https://doi.org/10.1016/j.ijid.2021.05.077
1201-9712/© 2021 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
treat Covid-19 patients (Thompson et al., 2020). They have
relearned medical skills and put aside their surgical knowledge
to help patients in their time of need (Adibe, 2021; How COVID-19,
2020). Due to the need for more hospital beds, temporary tents
were erected; when they became insufficient, many non-tradi-
tional areas were transformed into clinics, including endoscopy
units and even cafeterias. As a result, staff became increasingly
exhausted. The long list of patients and the overwhelming days and
nights during which many patients died due to the lack of ICU beds
and ventilators have forever made us question our role in this
critical scenario (Thompson et al., 2020; Adibe, 2021; Chughtai
et al., 2020; Ministro de Salud habla de la ocupación de las UCI en
Ecuador y dice que 86 000 dosis de vacunas se aplicarán en 43 000
personas de grupos prioritarios, 2021).
A year passed since the pandemic began, and the general
population had to forget the fear of the virus, especially when there
were many more immediate and deadly threats at hand (Balhareth
et al., 2020; Coronavirus en Ecuador, 2021). We had to turn our
sight on political and social issues, especially when the news about
Covid-19 became dangerously tedious (Balhareth et al., 2020).
Thus, more cases appeared and the number of patients requiring
intensive care became greater than ever. (Ministro de Salud habla
de la ocupación de las UCI en Ecuador y dice que 86 000 dosis de
vacunas se aplicarán en 43 000 personas de grupos prioritarios,
2021) Hospitals were pushed to total ICU capacity, and ICU staff
worked tirelessly with this high patient load, leading to a rise in the
Covid-19 mortality rate (Funerarias registran un 50% más de
servicios exequiales and Gremio dice que aparecieron negocios de
“garaje”, 2021; El Telégrafo, 2020).
What could have been done when there were no tools to help
patients? Many professionals resigned due to this complex
scenario. However, many continue to show resilience and keep
working even in these extreme situations. Holidays and days off
were and continue to be restricted; there are simply not enough
personnel to handle this pandemic. This feeling of self-reproach,
emotional and moral distress, risk of infection, fear of transmission
to family members, death of friends and colleagues, and the loss of
many patients, combined with long shifts and personal isolation
have affected doctors' ability to cope with an already stressful
profession (Ontiveros, 2020). Not only this, many professionals,
especially the young, who were seeking additional training or
looking for a fellowship program, the residents who were looking
for more suitable job positions, and the interns and students who
were expecting to learn more surgical skills before the pandemic
have been affected (Renuncia el ministro de Salud de Ecuador tras
el escándalo de vacunación - BBC News Mundo, 2021).
We were all denied these opportunities. Covid-19 demanded
our full attention, and despite this, we failed. The number of deaths
is so overwhelming that the official numbers have fallen short.
Letter to the Editor
Many patients have died undiagnosed, without being able to access
any testing or treatment. The Ecuadorian government acknowl-
edges that the coronavirus crisis is more severe than reported, a
fact that was recognized when the funeral system collapsed
(Funerarias registran un 50% más de servicios exequiales and
Gremio dice que aparecieron negocios de “garaje”, 2021; Renuncia
el ministro de Salud de Ecuador tras el escándalo de vacunación -
BBC News Mundo, 2021). The discovery of vaccines and the
promise of job stability to the personnel who serve in this
pandemic gave some hope. Yet, inadequate administration and
delays have disturbed an already weakened medical staff; this
feeling grew even worse when the wealthy and well-connected
were given access to the vaccine even before the first responders,
and long-term contracts were handed to personnel who had never
seen or worked beside a Covid-19 patient (El Telégrafo, 2020;
Renuncia el ministro de Salud de Ecuador tras el escándalo de
vacunación - BBC News Mundo, 2021).
We want to say that things are going to improve. We want to
feel that there is a light at the end of the tunnel and that everything
will be better when we are all vaccinated; however, the Ecuadorian
reality is worrying. Many of us have lost faith in our leaders and
authorities. We fear the day when this feeling of helplessness will
make us lose faith in our patients. We can only wait and show the
same resilience we have shown since the beginning of this
pandemic, not forgetting our calling. And above all remembering
that we have a critical mission to serve our patients – not the
system.
Contributions
GAM, concept, and drafting the manuscript; AVA, insight on the
manuscript and help during writing; SAE, conceptualization of
ideas; WGA, writing the manuscript and ideas around vaccines;
CLR, writing the manuscript and ideas around Covid-19 task force;
GEJ, conceptualization of ideas, in the hospital; MAM, insight on
the manuscript and help during writing; FXM, insight on the
manuscript and help during writing.
Funding
None.
Ethical approval
The ethics committee of our hospital has approved this
manuscript.
Acknowledgment
None.
References
Adibe B. COVID-19 and clinician wellbeing: challenges and opportunities. Lancet
Public Health 2021;6(3):e141–2, doi:http://dx.doi.org/10.1016/s2468-2667(21)
00028-1.
Balhareth A, AlDuhileb MA, Aldulaijan FA, Aldossary MY. Impact of COVID-19
pandemic on residency and fellowship training programs in Saudi Arabia: a
nationwide cross-sectional study. Ann Med Surg 2020;57:127–32, doi:http://dx.
doi.org/10.1016/j.amsu.2020.07.025.
Chughtai M, Minkara AA, Kuivila TE, Patterson BM. Implications of the COVID-19
pandemic on orthopaedic surgical residency and fellowship training: lost
opportunity or novel experience?. Ann Transl Med 2020;8(18), doi:http://dx.
doi.org/10.21037/atm-20-3777 1121–1121.
Coronavirus en Ecuador. No se pueden esconder los cadáveres. Antes en Guayaquil
había alrededor de 35 muertes por día, hoy 150. BBC News Mundo; BBC News
Mundo 2021;. . [Accessed 2 February 2021] https://www.bbc.com/mundo/
noticias-america-latina-52219012.
34
International Journal of Infectious Diseases 109 (2021) 33–35
Deutsche Welle. (www.dw.com. (2020). Ecuador concluirá el domingo estado de
excepción por pandemia | DW | 13.09.2020. DW.COM. 2020. https://www.dw.
com/es/ecuador-concluir%C3%A1-el-domingo-estado-de-excepci%C3%B3n-
por-pandemia/a-54909273.
El Telégrafo. 12 mil profesionales de la salud tendrán nombramientos definitivos. El
Telégrafo; 2020. https://www.eltelegrafo.com.ec/noticias/actualidad/44/medi-
cos-contratos-definitvos.
Funerarias registran un 50% más de servicios exequiales, Gremio dice que
aparecieron negocios de “garaje”. El Comercio. 2021. https://www.elcomer-
cio.com/actualidad/funerarias-levantamiento-cadaveres-covid-guayaquil.
html.
Giusti EM, Pedroli E, D’Aniello GE, Stramba Badiale C, Pietrabissa G, Manna C, et al.
The psychological impact of the COVID-19 outbreak on health professionals: a
cross-sectional study. Front Psychol 2020;11:, doi:http://dx.doi.org/10.3389/
fpsyg.2020.01684.
Hospitales enfrentan subida de casos con las UCI a tope. El Comercio. 2021. https://
www.elcomercio.com/actualidad/quito-covid-hospitales-pacientes-contagia-
dos.html.
How COVID-19. How COVID-19 will increase inequality in emerging markets and
developing economies. IMF Blog 2020;. . [Accessed 20 February 2021]. October
29 https://blogs.imf.org/2020/10/29/how-covid-19-will-increase-inequality-
in-emerging-markets-and-developing-economies.
Mehta S, Machado F, Kwizera A, Papazian L, Moss M, Azoulay É, et al. COVID-19: a
heavy toll on health-care workers. Lancet Respir Med 2021;, doi:http://dx.doi.
org/10.1016/s2213-2600(21)00068-0.
Ministro de Salud habla de la ocupación de las UCI en Ecuador y dice que 86 000
dosis de vacunas se aplicarán en 43 000 personas de grupos prioritarios. El
Comercio. 2021. https://www.elcomercio.com/actualidad/ministro-salud-
vacunacion-ecuador-coronavirus.html.
Noonan P. A Look Back at the Pandemic Year. WSJ; Wall Street J 2020;. . [Accessed 27
February 2021]. December https://www.wsj.com/articles/a-look-back-at-the-
pandemic-year-11608847540.
Ontiveros E. Coronavirus “second wave”: What lessons can we learn from Asia?. BBC
News; BBC News 2020;. . [Accessed 20 February 2021]. June https://www.bbc.
com/news/world-asia-52807255.
Renuncia el ministro de Salud de Ecuador tras el escándalo de vacunación - BBC
News Mundo. BBC News Mundo. BBC News Mundo 2021;. . [Accessed 28
February 2021] https://www.bbc.com/mundo/noticias-america-latina-
56210659.
Se registra el primer caso de coronavirus en Ecuador – Secretaría General de
Comunicación de la Presidencia. Comunicacion.gob.ec.. 2021. https://www.
comunicacion.gob.ec/se-registra-el-primer-caso-de-coronavirus-en-ecuador/
#:;:text=Ese%20fue%20el%20anuncio%20que,el%20pasado%2014%20de%
20febrero.
The Great Lockdown. The Great Lockdown: Worst Economic Downturn Since the
Great Depression. IMF Blog; IMF Blog 2021;. . [Accessed 20 February 2021]
https://blogs.imf.org/2020/04/14/the-great-lockdown-worst-economic-down-
turn-since-the-great-depression.
Thompson CN, Baumgartner J, Pichardo C, Toro B, Li L, Arciuolo R, et al. COVID-19
outbreak — New York City, February 29–June 1, 2020. MMWR Morb Mortal Wkly
Rep 2020;69(46):1725–9, doi:http://dx.doi.org/10.15585/mmwr.mm6946a2.
Waters M. This Pandemic Is Perilously Boring. Wired; WIRED 2020;. . [Accessed 27
February 2021]. March https://www.wired.com/story/this-pandemic-is-peril-
ously-boring.
Yo Me Cuido. “Yo Me Cuido”, la campaña del Gobierno Nacional para incentivar el
compromiso ciudadano – Secretaría General de Comunicación de la Presidencia.
2020 Comunicacion.gob.ec. https://www.comunicacion.gob.ec/yo-me-cuido-
la-campana-del-gobierno-nacional-para-incentivar-el-compromiso-ciudadano
[Accessed 2 February 2021].
Gabriel A. Molinaa,b,*
a
Department of General Surgery at Hospital Iess Quito Sur, Quito,
Ecuador
b
Universidad San Francisco de Quito (USFQ), Quito-Ecuador
Andres V. Ayalaa,b
a
Department of General Surgery at Hospital Iess Quito Sur, Quito,
Ecuador
b
Universidad Internacional del Ecuador, (UIDE), Quito, Ecuador
Santiago A. Endara
Hospital Metropolitano, Department of Surgery Division of Cardio-
thoracic Surgery, Quito, Ecuador
William G. Aguayo
Christian L. Rojas
Department of General Surgery at Hospital General San Francisco,
IESS, Quito, Ecuador
Letter to the Editor International Journal of Infectious Diseases 109 (2021) 33–35

Galo E. Jiménez * Corresponding author at: Department of General Surgery at

Department of General Surgery at Hospital Iess Quito Sur, Quito, Hospital Iess Quito Sur and Universidad San Francisco de Quito
Ecuador (USFQ).
E-mail address: gabomolina32@gmail.com (G. Molina).
Miguel A. Moyón
F.X. Moyón
Received 26 March 2021
Department of General Surgery at Hospital General San Francisco,
IESS, Quito, Ecuador

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